Saturday, May 31, 2014

Let's begin with explaining Men of System and Population Medicine Approach (PMA)

Adam Smith , in his first book, The Theory of Moral Sentiments spoke of the "man of system"

"The man of system, on the contrary, is apt to be very wise in his own
conceit; and is often so enamoured with the supposed beauty of his own
ideal plan of government, that he cannot suffer the smallest deviation
from any part of it. He goes on to establish it completely and in all
its parts, without any regard either to the great interests, or to the
strong prejudices which may oppose it. He seems to imagine that he can
arrange the different members of a great society with as much ease as
the hand arranges the different pieces upon a chess-board. He does not
consider that the pieces upon the chess-board have no other principle of
motion besides that which the hand impresses upon them; but that, in
the great chess-board of human society, every single piece has a
principle of motion of its own, altogether different from that which the
legislature might chuse [sic] to impress upon it. "

Dr. Harold C. Sox, , former President of the American College of Physicians (ACP) and former editor of the Journal of that organization, The Annals of Internal Medicine explains and seemingly recommends the PMA in a commentary in JAMA (November 33,2013) entitled 'Resolving the Tension Between Population Health and Individual Health Care ".

In this formulation it is claimed that one treats the population much as a physician would treat an individual patient.One uses the same "value metric" and the same few decision making principles. For example one would screen a given patient only if that would maximize that person's welfare and similarly in considering applying a screening procedure to a group would involve screening only those who would gain QALYs. Cox admits we don't really have all that information yet but "the challenge would be to develop models of the principal high stakes decisions of clinical medicine, perhaps starting by identifying these decisions and developing the evidence to inform them"We would need to determine the frequency,causes and consequences of the common medical conditions in a population and devise strategies for dealing with them over the life span. The public health system and the health care system and community leaders need to plan together.

Then resources could be allocated between disease-specific programs so that they would be moved from groups of patients less likely to benefit to groups more likely to benefit.

Sox then seems to admit there may be some growing pains with this approach but in the long run there will be benefit,. That is my paraphrasing now a quote :

"It will take several generations to realize the full benefit of investments in disease prevention. In the short run, these investments may draw resources away from tests and treatment for some sick people. In the long run,disease prevention and better low cost technology could reduce the outlay for treatment. In the interim, skillful clinical decision making can make the most of limited resources.

To make the population medicine approach operational it would be necessary for physicians to consider themselves practitioners of population medicine and support a system that "fairly allocates resources between the healthy many and sick few:" The Charter for Professionalism paves the way for that by admonishing physicians that they are the stewards of medical resources and that cost effectiveness is the new polar star.As long as physicians considered themselves to be fiduciary agents of their individual patients the scheme would not work. The publication of "Medical Professionalism in the New Millennium:A Physician charter" in 2002 was an important step in the movement to further the dogma of medical collectivism..

To achieve this medical utopia the Men of System of whom Adam Smith wrote will be required ; some one will be needed to move the different members of society around the chess board of utilitarian health care with its fair and cost effective allocation of health care resources. And while only a few physicians can be the Platonic Guardians ,some of whom will likely expend their energies on IPAB, the rank and file docs can work for the common good by adhering to guidelines.

Thursday, May 29, 2014

A recent article in BMJ has stirred more comments regards the possibility that there is a "j shaped" curve in regard to the relationship between level of exercise and development of atrial fibrillation (AF).

There have been number of publications addressing this issue and to my eye there is good evidence that there is an increased incidence of AF in long time endurance athletes. The magnitude of this increased risk and what this correlates with is less clear-duration of exercise,intensity, height?, genetic profile, confounding factors, etc etc.

The BMJ article is from Sweden by Nikola Drca and is a long term followup of over 44000 men who completed exercise questionnaires and provided in part retrospective estimates of hours per week exercised at ages 15,30, and 50.These questionnaires were then linked with data indicating whether they had developed AF.The AF numbers are relatively hard data the historical data much less so.

Of those men who said they exercised more than 5 hours per week at age 30 there was a relative risk (RR) of 1.19 (CI 1.05-1.36) this increased risk in the greater than 5 hour per week exercise category was only found for age 30, not at age 15 nor age 50 and the RR was higher for the high exercise at age 30 group who then stopped exercising (RR 1.49).

Several points come to mind

When the number in the study group is very large, very small differences in the measured outcomes become statistically significant. Relative risks less than 2-3 are generally not considered very convincing evidence that there may be causation.My favorite quote in this regard is from Michale Thur , epidemiologist at the American Cancer Society:,

With epidemiology you can tell a
little thing from a big thing.What's very hard to do is to tell a little
thing from nothing at all.

and a RR of 1.19 is pretty little

In trying to assess significance of RRs from observational epidemiology studies. it is sometimes useful to consider what is the prior evidence and look at biological plausibility (which old time internists like to think of sometimes as pathophysiology or disease mechanisms.)

There are a number of studies that suggest long term endurance athletes have a increased risk of AF but that is not what the data here suggest at all.The 30 year old heavy exercisers had increased risk while the 50 year old exercisers did not and there was even greater risk in those 30 year old heavy exercisers who quit. That does not seem like a dose response relationship, i.e more exercise more AF.

What would be the pathophysiology evoked to explain heavy exercise at 30 but not at 50 being related to increased risk of AF.

So what would be the take home advice? Don't begin heavy exercise until age 50 ? But if you are 30 and exercising a lot , don't quit.. None of that makes sense if we believe the is a j shaped curve regarding duration of exercise and risk of AF or if there is a positive relationship between duration of exercise and AF.I n spite of headlines emphasizing the 30 year old heavy exercisers risk I think overall the study is more reassuring to long time endurance athletes than it is concerning.The RR for the 30 year old group could easily be just statistical noise and the lack of increased risk for the others a more reliable finding.

For a more detailed and less biased discussion of this general topic I suggest the excellent blog written by Dr. Larry Creswell.

Disclosure of conflict of interest: I have been doing long distance running for almost 40 years .(Fortunately I did not begin distance running until after age 30,so there should be no problem). So, my mind set is to be critical of studies that purport to show a problem with too much running.

Thursday, May 15, 2014

Dr. Harold C. Sox has played a leadership role in the American College of Physicians for many years, serving as President of the ACP and long time editor of the Annals of Internal Medicine.

In the opening paragraph of a commentary in JAMA entitled "Resolving the Tension between Population health can individual health care" (JAMA November 13, 2013,Volume 310, number 18) he states:

"Perhaps the de facto organizing principle of US health care approaching each patient strictly as in individual is obsolete.The population heath approach is an alternative. It aims to improve and maintain health across a defined population."

Later repeating a major theme of the publication,"Medical Professionalism in the new millennium,a physician charter" , Dr Sox says:

"..the physician has an ethical imperative to balance the needs of the individual patient with the needs of society."

Dr. Sox then explains in broad terms how to practice population medicine.

"Planning to optimize population health will mean determining the frequency,causes and consequences of he common medical conditions in a population and devising strategies for dealing with them over a lifetime. "...
resources must be allocated across program to prevent,detect and treat disease and its risk factors. "...One reasonable principle to move resources from groups of patients less likely to benefit to groups more likely to benefit."

With the application of this utilitarian calculus there will be winners and losers which Sox seems to admit implicitly the following paragraph.

"It will take several generations to realize the benefit of investments in disease prevention.In the short run, these investments may draw resources away from the tests and treatment of some sick people.In the long run, diseased prevention and better low-cost technology could reduce the outlay for treatment."

So, in the short run the population medicine approach might deprive some sick patients of treatments but in the long run "the outlay for treatment " could be reduced. Withholding treatment for those who are sick now for some purported,future , hypothetical benefit to anonymous people is completely antithetical to basic medical ethics and has no place in a nation with any remnant of individual freedom remaining.

Dr. Sox after already seemingly condoning sacrifice of the individual's welfare to some nebulous greater social good then closes the commentary with the following platitude which seems to contradict his earlier statements;
"Much of medical practice has changed but not the basis of patient -centered care."

The term "patient centered care" is a trendy, feel-good cliche without well defined operational meaning but I cannot believe that any generally accepted understanding of that phrase could possibly include not treating the sick to gain some allegedly future benefit to some some subset of well people.

As someone who did his medical training in the same time frame as Dr. Sox in which the notion of the physician as the fiduciary of the patient was sacrosanct I find his comments wrong on so many levels that I cannot find the words to express it but to the extent that views such as those expressed in his commentary are more widely accepted there is reason to be afraid,very afraid.

Dr Michel Accad critiqued this creed of medical collectivism in his blog writing in part:

"...beyond ignoring the obvious tension between the individual and the group, hoodwinking physicians into practicing "population medicine" is of course the essential means to confuse practitioners into thoughtlessly carrying out sweeping interventions whose primary benefit is the profit of third parties."

Monday, May 12, 2014

The concept "social justice" was the bait. The folks at ABIM, ABIMF, ACP and RWJ declared without even a token effort at historical justification that part of professionalism for physicians was social justice. That 2002 publication entitled " Medical Professionalism in the New Millennium.A physician charter " did not specify exactly how physicians might work for social justice in their role as physicians.Neither did they offer an operational meaning for social justice which is par for course for folks who promote a collectivist agenda, the ambiguity having significant rhetorical value.Progressive and liberals love the notion of social justice and would readily give their approval to this new and improved medical professionalism. Conservatives and libertarians not so much but some went alone to get along to avoid accusations of political incorrectness.

Now the switch. Physicians could/should work for social justice by being stewards of society's scarce medical resources and that could be done by following guidelines and in that way a fair and equitable distribution of resources could be brought about.

Never mind that the most widely acceptable definition of social justice is redistribution of resources from those who can afford it to those more disadvantaged. This in not what is being promulgated. The ABIM (F) and ACP and RWJF are advocating for parsimonious care in their Choosing Wisely campaign which to the degree it is successful will decrease care for everyone, at least everyone who depends on their insurance ( private or public) for medical care. Who gains ? The third party payers and the medical progressive elite and fellow travelers who write the guidelines.

Dr, Scott W Atlas writes here about the two tiered health care that Obamacare will intensify, an interesting irony since folks who continue to defend Obamacare insist that one of the success of it is to further social justice. This is a strange social justice in which the poor and middle class may get less care while the connected and wealthy will do much better and in which the young and well subsidize the older and sicker folks even though many of the older are financially better off if only because they may have remnants of lifetimes of earnings.

Tuesday, May 06, 2014

No longer do the third party payers (TPP) have to deal with the physicians and patients working against their bottom line. Physicians, patients and the TPP will work together in harmony in the land of rainbows,unicorns and the big rock candy mountain.All the stakeholders can get together and work on ways to eliminate waste,low value care and conserve the third party payer's society's scarce resources.Actually TPP have not been dealing with physicians for some time now, they interact with providers of health care.

The following dream of the TPPs might just be coming true:

Careful analysis of aggregate data in which patients will gladly participate will allow cost effective guidelines to be written and executed as all players will realize the wisdom in maximizing the health and well being of the population.The utilitarian ethic of the greatest good for the group will be recognized as the only sensible alternative to the selfish pursuit of individual gain which previously motivated both the selfish patient,concerned as she was with her own health and the health of her family and the avaricious physician,driven as he was by the flawed and destructive fee for service system. Value not quantity will be served .

Third party payers should be eternally grateful to the progressive thinking leadership of such organizations as the American Board of Internal Medicine and its foundation,the ABIMF (which was generously funded by the thousands of socially minded internists who sat for repeated examinations) and the thought leaders at The American College of Physicians (ACP) who managed to convince many that providing less care is better for everyone not the least of which are the third party payers and the medical progressive elite who alone will have the wisdom and expertise to determine what is best for everyone.

Can the Choosing Wisely campaign be explained by 1)the follow the money principle and 2)the Baptist and Bootlegger story.

Of course , the dream perhaps had not been completely realized yet. There are still obstacles to overcome;

1) the self interest of the patient and the patient's family. Most people do not think when they develop chest pain " I'm going to the Emergency Room to see how the Doctor can balance my immediate needs with those of society. In other words, one aspect of that darned incentive problem.It is hard to stamp out that pesky tendency of folks to try and act in their own interests and in the interest of those they care deeply about.

2 )that pesky Mal-practice issue . So far the argument that Mr..Jones did badly but it was OK because we followed the latest cost effectiveness guideline has not risen to the level of a major legal defense

3) Reminiscent of the WWII. Japanese soldiers who held out for years on isolated islands not aware they had lost, there are still some physicians who,perhaps educated in an earlier era with a different and less enlightened ethical upbringing , still believe and as if they are the fiduciaries of their patient.Perhaps time will take care of those dead-enders but until then the TPP utopia will not be completely realized in spite of the well funded campaign to convince physicians of their duty to conserve medical resources by following guidelines.